Rothman Concussion Network

Search

ImPACT Questionnaire

Name*
Invalid Input

Date of Birth*
Invalid Input

Email*
Invalid Input

(to receive a copy of this questionnaire for your records)

Height*
Invalid Input

ft / in

Weight*
Invalid Input

lbs

Gender*
Invalid Input

School*
Invalid Input

Grade in school*
Invalid Input

Handedness*
Invalid Input

Native Language*
Invalid Input

Second Language (if applicable)
Invalid Input

Ethniticy (optional)
Invalid Input

Do any of the following apply to you?

Speech Therapy?*
Invalid Input

Attended Special Education Classes?*
Invalid Input

Repeated One or More Grades in School?*
Invalid Input

Diagnosis of a Learning Disability?*
Invalid Input

What Type of Student Are You?*
Invalid Input

Current Sport*
Invalid Input

Current Position / Event / Class*
Invalid Input

Current Level of Participation*
Invalid Input

Years of Experience at This Level*
Invalid Input

(approximate if uncertain, please do not include current year i.e. high school senior = 3 years)

Number of times diagnosed with a concussion*
Invalid Input

Total number of concussions that resulted in loss of consciousness*
Invalid Input

Total number of concussions that resulted in confusion*
Invalid Input

Total number of concussions that resulted in difficulty with memory for events occurring immediately after injury*
Invalid Input

Total number of concussions that resulted in difficulty with memory for events occurring immediately before injury*
Invalid Input

Total games were missed as a direct result of all concussions combined*
Invalid Input

Please list your five most recent concussions (Month / Year)*
Invalid Input

Indicate whether you have experienced the following:

Have you been treated for headaches by a physician?*
Invalid Input

Have you been treated for migraine headaches by a physician?*
Invalid Input

Do you have a history of Epilepsy/seizures?*
Invalid Input

Do you have a history of brain surgery?*
Invalid Input

Do you have a history of meningitis?*
Invalid Input

Have you received treatment for alcohol/substance abuse?*
Invalid Input

Have you received treatment for a psychiatric condition (depression, anxiety)?*
Invalid Input

Have you ever been diagnosed with any of the following conditions?

ADD/ADHD?*
Invalid Input

Dyslexia?*
Invalid Input

Autism?*
Invalid Input

Date of last concussion
Invalid Input

Current Medications:
Invalid Input

Are you a robot?
Invalid Input

For Your Brain The Best Minds

For Your Brain The Best Minds

Thank you for visiting the former Jefferson Comprehensive Concussion Center website. We are now proudly owned and operated by the Rothman Institute Concussion Network. Please take a moment to explore our new website. If you would like to contact Jefferson, please call 1-800-JEFF-NOW. To schedule an appointment with the Rothman Concussion Network, call 267-463-2300 or visit our Make an Appointment Page.